Ready for SDM: evaluating a train-the-trainer program to facilitate implementation of SDM training in Norway

BackgroundAlthough shared decision making (SDM) is key to delivering patient-centred care, there are barriers to GPs implementing SDM in practice. SDM training is undergoing development by organisations, including the Royal College of General Practitioners. However, GPs’ perceptions of the delivery of SDM training in general practice remain largely unexplored.AimTo explore GPs’ perceptions of teaching methods in SDM training.Design and settingQualitative study of GPs with teaching roles at the University of Exeter Medical School.MethodPurposive sampling recruited 14 GPs. Semi-structured interviews explored their SDM educational experiences. Data were analysed using thematic framework analysis.ResultsThree themes were identified. The GPs described role-play, receiving feedback, and on-the-job learning as modes of delivering SDM training that mostly informed their SDM in clinical practice positively. Learning from knowledgeable individuals and using realistic patient cases were perceived as beneficial components of SDM learning, although most learning occurred implicitly through reflections on their clinical experiences. The GPs identified that their training on SDM should reflect the uncertainty that is present when sharing decisions with patients in real-life general practice consultations. GPs also identified the targeting of individual GPs’ SDM learning needs and explanation of the potential benefits of SDM on consultation outcomes as important methods to facilitate the implementation of SDM in practice.ConclusionTo the authors’ knowledge, this is the first UK study to explore GPs’ perceptions of SDM training and provide recommendations for practice. As SDM occurs in partnership with patients, further research should obtain and incorporate patients’ views alongside those of GPs in the evaluation of future programmes.

420 Background: To align BC treatment with patient goals, it is vital that healthcare providers (HCPs) engage their patients (pts) in SDM for treatment planning. We assessed alignment and discordances on aspects of SDM among BC pts and their urology and oncology teams. Methods: Between 05/2020 and 06/2020, surveys were administered to 53 pts with BC (48% female, mean age 68 years) and 23 HCPs, as part of in-clinic and virtual collaborative patient education sessions across 5 US-based practices. Surveys were designed to assess perceptions, preferences, and experiences with regard to SDM during BC care. Results: Survey findings indicated key alignments and discordances in pts’ reported experience and HCPs’ perceptions of the use of SDM in BC care. HCPs and pts identified the same top 2 patient goals for BC care: 1) preventing progression/recurrence (61% pts, 48% HCPs) and 2) maintaining quality of life (35% pts, 78% HCPs). When asked to identify patient’s top challenges for pts in BC care, both pts and HCPs indicated post-treatment aspects as the top challenge, though pts indicated managing side effects/serious worry about side effects from treatment as the top challenge (22%); whereas, HCPs were split evenly between managing side effects from treatment (26%) and managing life changes as a result of urinary diversion (26%). HCPs overestimated the effect that fatigue and worry had on pts capacity for SDM: only 9% of pts indicated worry or fatigue as a barrier to SDM, but 65% of HCPs indicated this as a likely barrier. Furthermore, the patient experience of SDM differed from HCP perception of SDM (Table); for some aspects of SDM, such as explaining different treatment options, explaining pros/cons of treatment options, and overall involvement in treatment decisions, fewer HCPs indicated that these aspects of SDM always or usually occurred as compared to pts. Conclusions: These findings reveal important alignments and discordances between pts and HCPs with regard to BC care and SDM, which may inform future bladder cancer and SDM initiatives. [Table: see text]

Background. Shared decision making (SDM) is an essential component of patient-centered care and especially important in high-risk populations, such as older adults. Although surgery has unique risks and the potential to cause permanent disability, which can affect the patient’s quality of life, SDM is underused before surgery to explore these tradeoffs. This study’s aim is to characterize the priorities, barriers, resources, and age-specific considerations for SDM in older adults undergoing surgery. Study Design. Five semi-structured focus groups were completed from February 2022 to April 2022 with 24 participants including older adult surgical patients and caregivers as well as providers involved in the care of older adult surgical patients (e.g., surgery, intensive care, geriatrics, and palliative care). Interviews were transcribed, and qualitative thematic analysis was conducted. Results. Six major themes were identified and explored: components of SDM, barriers to SDM, importance of SDM, preparation for SDM, age-specific considerations, and suggestions for improvement. Results showed differing opinions between patients and providers about important information in the SDM process, minimal preparation for SDM in both groups, and difficulties around defining outcomes for this population, particularly in the emergent setting. Conclusion. This study identifies critical components of SDM, perceived barriers, preparation and training for SDM, as well as unique considerations in older adults from the perspectives of both patients and providers. Opportunities to improve SDM include dissemination of resources, training of surgical providers, and utilization of other providers as well as patient-centered discussions about postoperative outcomes. This highlights important areas for future work and particularly the utility of SDM tools and training for surgeons.HighlightsCritical components of shared decision making (SDM) identified in this study include understanding patient values, building trust, understanding the patient’s baseline function, and defining possible treatment outcomes.Specific components of SDM in older adults include navigating companions to conversations and the challenges of navigating potential postoperative changes to cognitive or physical function.Possible areas to improve SDM include improved dissemination of SDM resources; the importance of communication skills and empathy and an emphasis on additional training for this, particularly for trainees; improved engagement of patients in the SDM process; and using other care team members such as palliative care and social work when appropriate.

Use and Perceptions of Shared Decision-Making by General Surgery Faculty and Trainees.

Discordant Beliefs, Perceptions, and Experiences between Patients with Sickle Cell Disease and Their Care Teams: Insights from a Pilot Program to Support Shared Decision-Making

1547 Background: In the rapidly evolving treatment landscape of metastatic breast cancer (MBC), shared decision-making (SDM) is critical to individualize care and improve patient outcomes. To help facilitate improved SDM, we developed an educational toolkit for health care providers (HCPs) to use with HR+/HER2- and triple negative breast cancer (TNBC) patients (pts) and evaluated the implementation of this toolkit at 5 community oncology clinics. Methods: In May-June 2022, pts (N=94) and HCPs (N=18) completed surveys assessing attitudes, confidence, goals, and barriers to SDM in MBC care. HCPs then led collaborative learning sessions with their pts using the SDM toolkit to provide education regarding treatment options and side effects, and to better align on shared goals and treatment plans. Results: In surveys, only 50% of pts reported that they decide on a treatment plan together with their HCPs , 38% reported being asked about treatment preferences, and 34% reported discussing supportive care, such as mental health care or pain relief. Additionally, very few pts reported high knowledge of BC treatments and side effects. HCPs and pts were misaligned on patient goals and barriers to SDM. For example, 56% of HCPs thought pts were too overwhelmed/anxious/fatigued to make treatment decisions, but only 21% of pts agreed that was a top challenge. While pts and HCPs were aligned on top treatment decision factors of effectiveness and quality-of-life, HCPs underestimated the importance of concerns about side effects (HCPs 11% vs pts 32%), and the cost and duration of treatment (17% vs 30%, and 22% vs 30%, respectively). HCPs correctly identified survival (56%) as a top goal for pts but were less likely to identify progression/recurrence as important to pts (39%). Additionally, 28% of pts reported their top challenge was worrying about being unable to work or meet responsibilities at home; however, only 19% of HCPs recognized this as a top challenge. Following pt-HCPs collaborative education sessions, in which HCPs used the SDM toolkit to facilitate pt education and SDM, HCPs and pts reported improved confidence in pt-HCP communication. Additionally, 46% of pts reported discussing treatment goals with their HCPs and 46% reported taking a more active role in their care following the learning session. Conclusions: These findings reveal misalignments between HCPs and patients with BC regarding treatment decision-making. The gaps identified are critical to address as they are pre-requisites for SDM. The downloadable shared decision-making toolkit developed as part of this implementation science initiative can be adopted by breast cancer clinical teams to help facilitate patient education and SDM, empowering patients to be active participants in their care.

<i>Background &amp; rationale: </i>Evidence-based medicine (EBM) requires doctors to use their clinical expertise, the best current research evidence, and patient preferences to make optimal healthcare decisions. Healthcare systems recognise the importance of patient involvement in their care and recommend the practices of person-centred care and shared decision-making (SDM), where the doctor and patient make care decisions together. However, training in EBM has not kept pace with these developments, which has impacted doctors’ ability to effectively apply EBM principles to patients in their care. It has been suggested that training courses in EBM that incorporate principles of SDM can improve the inclusion of patient preferences into the EBM process and improve patient experiences and outcomes, such as compliance with a healthcare plan. However, there has been little research into how to train junior doctors to include the patient in EBM decision-making. <i>Objectives: </i>The overall aim of the thesis was to understand how training that integrates EBM and SDM can change junior doctors’ attitudes and intended practice of both concepts, and the barriers and facilitators to these changes. <i>Research articles: </i>This thesis contains five articles. Article I is a systematic review of the EBM training programs available for junior doctors, and how their outcomes are measured. Articles II and III are a scoping review and its protocol that examined whether EBM courses for junior doctors include SDM. Articles IV and V are empirical studies that explored the attitudes and perspectives of junior doctors and consultants about EBM and SDM. <i>Methods: </i>The research centred around an intervention, an EBM training course that included a component on SDM. An explanatory sequential research design used a mixed methods survey, and two rounds of interviews. Participants were junior doctors and consultants from a private health care setting on a university campus in Sydney. <i>Research findings</i>: Findings demonstrated junior doctors’ attitudes towards EBM and SDM were more positive following the training course. The findings also highlighted the barriers to the combined EBM and SDM practice experienced by junior doctors, in particular time factors, lack of prior training, and the medical hierarchy. <i>Contributions of the thesis: </i>By providing insights into existing gaps in EBM and SDM training, this thesis has identified key barriers to EBM-SDM learning and practice, and indicated ways of overcoming them, such as using champions to promote EBM and SDM learning and practice in clinical settings.

Shared decision making for high-risk surgery

Navigating shared decision-making in lung cancer screening: Insights into barriers, training, and referral propensity among clinicians.

ABSTRACTTraining in shared decision-making (SDM) often focuses solely on dyadic relationships between one healthcare provider and one patient. However, many healthcare decisions often involve two or more health professionals. These decisions warrant utilizing an interprofessional shared decision-making (IP-SDM) approach which enables patients and their caregivers to face difficult decisions around care together. Most existing SDM training programs fall short when building interprofessional (IP) competencies and require an approach that integrates IP with SDM. This short report discusses the creation and trial implementation of three enhanced education tools (a video, role-play exercise with decision aid, and an IP observation aid) for an IP-SDM workshop focused on helping homecare teams collaborate with seniors and their caregivers throughout the decision-making process. We developed and implemented these tools in eight study sites of a larger randomized control trial to test the training workshop for homecare teams. The workshop and tools helped participants overcome interprofessional challenges in their work. Participants evaluated the tools and workshop, which offered guidance to better translate teachable IP collaboration competencies within SDM.

Historically, the role of the health-care provider in medical practice has been primarily paternalistic by offering information, compassion, and decisive views with regard to medical decisions. This approach would exclude patients in the decision-making process. In a shift toward more patient-centered care, health-care providers are routinely encouraged to practice shared decision making (SDM). SDM uses evidence-based information about the options, elicitation of patient preferences, and decision support based on the patient's needs with the use of decision aids or counseling. Although there are well-known benefits of SDM, including improvements in psychological, clinical, and health-care system domains providers have found it challenging to apply SDM in everyday clinical practice. In allergy, we have a unique role in the treatment of children and adults, and SDM should be applied appropriately when engaging with these specific groups. There are many situations in which there is not a clear best option (food allergy testing, food introduction and challenges, and immunotherapy). Therefore, decision aids specific to our field, coupled with evidenced-based information that ultimately leads to a decision that reflects the patient's values will make for a vital skill in practice. In this article, we defined SDM, the benefits and barriers to SDM, unique situations in SDM, and approach to SDM in food allergy.

BackgroundHypertension is one of the key factors causing cardiovascular diseases. A substantial proportion of treated hypertensive patients do not reach recommended target blood pressure values. Shared decision making (SDM) is to enhance the active role of patients. As until now there exists little information on the effects of SDM training in antihypertensive therapy, we tested the effect of an SDM training programme for general practitioners (GPs). Our hypotheses are that this SDM training (1) enhances the participation of patients and (2) leads to an enhanced decrease in blood pressure (BP) values, compared to patients receiving usual care without prior SDM training for GPs.MethodsThe study was conducted as a cluster randomised controlled trial (cRCT) with GP practices in Southwest Germany. Each GP practice included patients with treated but uncontrolled hypertension and/or with relevant comorbidity. After baseline assessment (T0) GP practices were randomly allocated into an intervention and a control arm. GPs of the intervention group took part in the SDM training. GPs of the control group treated their patients as usual. The intervention was blinded to the patients. Primary endpoints on patient level were (1) change of patients’ perceived participation (SDM-Q-9) and (2) change of systolic BP (24h-mean). Secondary endpoints were changes of (1) diastolic BP (24h-mean), (2) patients’ knowledge about hypertension, (3) adherence (MARS-D), and (4) cardiovascular risk score (CVR).ResultsIn total 1357 patients from 36 general practices were screened for blood pressure control by ambulatory blood pressure monitoring (ABPM). Thereof 1120 patients remained in the study because of uncontrolled (but treated) hypertension and/or a relevant comorbidity. At T0 the intervention group involved 17 GP practices with 552 patients and the control group 19 GP practices with 568 patients. The effectiveness analysis could not demonstrate a significant or relevant effect of the SDM training on any of the endpoints.ConclusionThe study hypothesis that the SDM training enhanced patients’ perceived participation and lowered their BP could not be confirmed. Further research is needed to examine the impact of patient participation on the treatment of hypertension in primary care.Trial registrationGerman Clinical Trials Register (DRKS): DRKS00000125

Shared decision making with schizophrenic patients: a randomized controlled clinical trial with booster sessions (DECIDE Study)

While shared decision-making (SDM) training programmes for health professionals have been developed in several countries, few have been evaluated. In Norway, a comprehensive curriculum, "klar for samvalg" (ready for SDM), for interprofessional health-care teams was created using generic didactic methods and guidance to tailor training to various contexts. The programmes adapted didactic methods from an evidence-based German training programmes (doktormitSDM). The overall aim was to evaluate two particular SDM modules on facilitating SDM implementation into clinical practice. A descriptive mixed methods study using questionnaires and a focus group guided by the Medical Research Council Complex Interventions Framework. The training was provided as two different applications (module AB [introduction and SDM-basics] and module ABC [introduction, SDM-basics and interactive training]) with differing learning objectives, extent of interactivity, and duration (1 vs 2 hours). Groups of participants were recruited consecutively based on requests for health professional SDM training in university/college- and hospital-settings. By a focus group and a self-administered questionnaire comprehensibility, relevance and acceptance were assessed and qualitative feedback collected after the training. Data passed descriptive and content analysis, respectively. Knowledge was assessed twice using five multiple-choice items and analysed using paired t-tests. In 11 (six AB and five ABC) training sessions, 357/429 (296 AB and 133 ABC) eligible nurses, physicians and health professional students with varying clinical backgrounds and previous levels of SDM-knowledge participated. SDM-knowledge increased from 25-78% (range pretest) to 85-95% (range post-test) (P ≤ .001). The training was rated easy to understand, acceptable and relevant for practice. Findings to improve the education suggest higher emphasis on interprofessional teaching methods. The two SDM training modules met the basic requirements for use in a broader SDM implementation strategy and can even improve knowledge.

Background. Shared decision making (SDM) involving adolescents with chronic conditions is a triadic process that requires engaging adolescent patients, their parent(s), and their health care provider. We sought to understand the perspectives of parents about these interactions and the parents’ role in SDM. Methods. We conducted semi-structured qualitative interviews with parents of adolescents (aged 12–17 y) with chronic conditions. The interviews focused on parents’ experiences of medical decision making related to their adolescent’s care, followed by experiences of SDM. We specifically addressed key aspects of SDM including information exchange, options, values, and preferences. We coded and analyzed the interviews using thematic content analysis. Results. Twenty-one parents completed an interview (median age 44 y, 91% female, 53% non-White). We identified 4 themes from the data: parents want an executive role, parents as experts, parents’ perceptions of others’ roles, and parents’ necessities for SDM. Parents described wanting to control the level to which their adolescent is involved in SDM based on their perceived knowledge of their adolescent’s capabilities. Parents reported feeling pressure to understand all aspects of potential decisions. Finally, parents underscored the need for trusting relationships between all members of the triad. Conclusions. Parents identify key roles for themselves and others in triadic SDM. By understanding these perspectives, health care providers may be better prepared to promote SDM in the care of adolescents with chronic conditions. Implications. This research has implications for how decisions are shared between providers and families. Valuing parents and including them in decision making has the potential to establish stronger relationships between the family and the care team and reduce parents’ anxiety about their child’s health.HighlightsThis study is the first to explore parents’ perspectives of triadic SDM involving an adolescent with a chronic condition.We identify situations (e.g., non–life-threatening treatment decisions, before an impending transition to adult medicine) in which parents may be more amenable to including their adolescent in the decision process.Understanding parents’ perspectives on decision making can help providers establish strong relationships with the families, which may improve care for adolescents with chronic conditions.